We describe three young women with iron deficiency anemia who developed ischemic strokes in the absence of typical risk factors.

Ischemic stroke is the third leading cause of death in women.  Women have unique risk factors for ischemic stroke.  Iron deficiency anemia disproportionately affects premenopausal women and has previously been identified to be associated with ischemic stroke.    

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A 39-year old woman with hypertension and menorrhagia presented with left leg weakness and dizziness.  Labs revealed a hemoglobin of 5.9g/dL, a unremarkable hypercoagulable work up, transesophageal echo, urine toxicology, rheumatological evaluation, and MRA brain vessel wall imaging.  An ultrasound of her uterus revealed a pelvic fibroid measuring 6.5cm and MRI brain revealed a small right anterior cerebral artery territory infarction.  

A 46-year-old woman with chronic iron deficiency anemia with a hemoglobin of 6.8g/dL who presented with left mild sided weakness and was found to have a right MCA M3 occlusion by CT angiography of the head.  She received intravenous tenecteplase and underwent decompressive craniectomy for a right temporal infarct associated with cerebral edema seen on MRI brain.  Investigations revealed a normal hemoglobin electrophoresis, urine toxicology, hypercoagulable evaluation, rheumatological evaluation and transesophageal echo.

A 43 year old woman presented with diplopia secondary to a vertical gaze palsy.  MRI brain revealed an infarct in the left thalamus, cerebral peduncle, and midbrain.  Cerebral angiography, transesophageal echocardiogram, urine toxicology, rheumatological evaluation, and hypercoagulable work up were unremarkable.  Hemoglobin was 7.2g/dL on presentation and an EGD revealed an antral and duodenal ulcer.

All three patients received packed RBC transfusions, iron replacement therapy and discontinuation of aspirin until hemoglobin stabilized.  

Iron deficiency anemia may be an important yet under-recognized risk factor for acute ischemic stroke and should be treated aggressively in premenopausal women.  Further studies are warranted.